Primary follicular lymphoma of the duodenum is a distinct mucosal/submucosal variant of follicular lymphoma: a retrospective study of 63 cases

PURPOSE

Small series with limited follow-up have suggested primary follicular lymphoma of the duodenum (FL-D) to be an indolent disease. We report our experience on a large series of patients followed for a median time period of longer than 6 years.

PATIENTS AND METHODS

The study comprised 63 patients with primary FL-D defined as stage I disease. Endoscopy and detailed pathologic work-up was performed at diagnosis and at restaging to monitor the behavior of the neoplastic process.

RESULTS

Histologically, all 63 patients had FL, low grade (1 to 2). Duodenal endosonography demonstrated lesions confined to mucosa/submucosa in 19 of 20 patients. At an overall median follow-up of 77 months (range, 12 to 177 months), only two untreated patients had developed nodal disease, the remaining 61 patients never experienced extrasmall intestinal disease and large cell transformation did not occur at all. Among 24 patients followed by watch and wait strategy, seven showed spontaneous complete regression and 17 had stable disease; radiotherapy resulted in complete regression in all 19 patients; anti-CD20 antibody monotherapy achieved complete regression in four patients and stable disease in one patient. Various chemotherapy protocols in eight patients caused complete regression in all of them, but local relapses occurred in three. No patients required surgery or died of disease.

CONCLUSION

These findings characterize primary FL-D as a remarkably indolent FL variant, which, even left untreated, does not develop tumorous growth, very rarely disseminates (two of 63 patients) and does not transform to high grade disease. A watch and wait approach appears to be the most sensible strategy.

Correlation of serum pepsinogens and gastrin-17 with atrophic gastritis in gastroesophageal reflux patients: a matched-pairs study

BACKGROUND AND AIM

An algorithm (GastroPanel) for the non-invasive diagnosis of atrophic gastritis has been previously proposed, based on serum pepsinogen-I, gastrin-17, and Helicobacter pylori (H. pylori) antibodies. The aim of the present study was to evaluate whether serum markers correlate with and predict gastric atrophy in gastroesophageal reflux disease (GERD) patients.

METHODS

The baseline data of the prospective ProGERD study, a study on the long-term course of GERD (n=6215 patients), served to select patients with atrophic gastritis diagnosed in biopsies from gastric antrum and corpus, and control cases without atrophy. A total of 208 pairs were matched for age, sex, GERD status (erosive vs non-erosive), presence of Barrett's esophagus, and histological H. pylori status were retrieved. Serum pepsinogen-I, gastrin-17, and H. pylori antibodies were determined using specific enzyme immunoassays.

RESULTS

A significant negative correlation was found between the degree of corpus atrophy and the level of serum pepsinogen-I. A previously-reported negative correlation between the degree of antral atrophy and serum gastrin-17 could not be confirmed. The low sensitivity (0.32) and specificity (0.70) of the GastroPanel algorithm were mainly due to over diagnosis and under diagnosis of advanced atrophy in the antrum.

CONCLUSION

The diagnostic validity of the GastroPanel algorithm to diagnose gastric atrophy non-invasively is not sufficient for general use in GERD patients.

Clinical trial: a novel high-dose 1 g mesalamine suppository (Salofalk) once daily is as efficacious as a 500-mg suppository thrice daily in active ulcerative proctitis

BACKGROUND

Mesalamine suppositories are first-line therapy in active ulcerative proctitis; the standard regime still recommends multiple doses per day. The primary objective of this study was to show the noninferiority of once-daily administration of a novel 1 g mesalamine suppository versus thrice-daily administration of the 0.5 g mesalamine suppository.

METHODS

This was a single-blind (investigator-blinded), randomized, multicenter, comparative, Phase III clinical trial. Patients with mild to moderately active ulcerative proctitis inserted either one mesalamine 1 g suppository at bedtime or one mesalamine 0.5 g suppository thrice daily over a 6-week period. The primary endpoint was rate of remission (Disease Activity Index below 4).

RESULTS

In all, 354 patients were evaluable for safety and per-protocol analysis. The new regimen demonstrated noninferiority: The percentage of patients with remission was 87.9% for the once-daily 1 g mesalamine suppository and 90.7% for the thrice-daily 0.5 g mesalamine suppository. Each regimen resulted in prompt cessation of clinical symptoms (e.g., median time to ≤3 stools per day (all without blood): 5 days in the 1 g mesalamine once-daily and 7 days in the 0.5 g mesalamine thrice-daily group). Patients preferred applying suppositories once a day.

CONCLUSIONS

In active ulcerative proctitis the once-daily administration of a 1 g mesalamine suppository is as effective and safe, yet considerably more convenient, than the standard thrice-daily administration of a 0.5 g mesalamine suppository.

Twelve-month endoscopic and histological analysis following proton-pump inhibitor-based triple therapy in Helicobacter pylori-positive patients with gastric ulcers

OBJECTIVE

To evaluate endoscopic and histological findings after Helicobacter pylori eradication therapy in gastric ulcer (GU) patients after 12 months' follow-up.

MATERIAL AND METHODS

A total of 401 GU patients were randomized to receive either twice-daily (b.i.d.) esomeprazole 20 mg+amoxicillin 1000 mg+clarithromycin 500 mg (EAC) for 1 week followed by placebo for 3 weeks, EAC followed by once-daily (o.d.) esomeprazole 20 mg for 3 weeks or esomeprazole 20 mg b.i.d. plus placebo antibiotics for 1 week followed by esomeprazole 20 mg o.d. for 3 weeks. Endoscopy with biopsy was performed at baseline, after treatment and at 6 and 12 months' follow-up (healed patients).

RESULTS

Endoscopic abnormalities, particularly in the stomach, were common at baseline and remained similar during follow-up, regardless of ulcer status and treatment. Helicobacter gastritis was present (antrum or corpus) in approximately 20% of patients following eradication therapy (versus approximately 80% with esomeprazole alone); these effects were sustained during follow-up. Similar trends were observed for other histological variables (granulocyte and lymphoplasmocytic cell infiltration, replacement of gastric surface cells by regenerative epithelium, and mucous depletion). No changes in atrophy or intestinal metaplasia were observed. Eighteen gastric cancer cases were detected: 11 at baseline endoscopy, and seven during treatment and follow-up.

CONCLUSIONS

Endoscopic abnormalities are common in GU patients and persist after proton-pump inhibitor-based triple therapy for H. pylori eradication, which is associated with large, sustained improvements in histological variables. Follow-up endoscopy and histology may be necessary, even in patients with apparently non-malignant GU, to improve the detection rate of gastric malignancy in populations with a high prevalence of gastric cancer.

[Diagnosis of early neoplasia in Barrett's mucosa based on changes in surface structure. Comparative stereo-microscopic and histological investigations in 600 endoscopically resected specimens]

BACKGROUND

In view of the rapidly increasing incidence of Barrett's carcinoma, a desirable aim would be to detect intraepithelial neoplasia and mucosal carcinoma via the endoscope. Where something new is growing, it should give rise to visible changes in surface structure, in particular, in the case of the early Barrett's neoplasia. The present study was carried out to investigate this hypothesis.

PATIENTS AND METHODS

A total of 600 formalin-fixed endoscopically resected specimens (317 patients) from Barrett's oesophagus were prospectively investigated by stereomicroscopy (magnification up to x 90). The surface structure was classified into regular (finely granulated or ridged gyriform) and irregular (coarsely granulated, polypoid elevated or depressed), and compared with the results of the histological evaluation.

RESULTS

88.5 % of the Barrett's carcinomas, and 76 % and 68 %, respectively, of the cases of high-grade and low-grade intraepithelial neoplasia were associated with an irregular surface structure. However, coarsely granulated mucosal surfaces, reflecting regenerative changes, were also found in 26 % of the cases of Barrett's mucosa without intraepithelial neoplasia.

CONCLUSION

Despite formalin fixation, 68 - 88.5 % of the cases of early Barrett's neoplasia can be identified by stereo microscopy. This shows that high-resolution videoendoscopy or magnification endoscopy appears to be a highly suitable method for the targeted detection of early Barrett's neoplasia.

Early Barrett's carcinoma: the depth of infiltration of the tumour correlates with the degree of differentiation, the incidence of lymphatic vessel and venous invasion

The incidence of regional lymph node metastasis in early Barrett's carcinoma is determined by the depth of infiltration of the tumour. The present study investigated the possible relationship between the depth of infiltration of the tumour, its degree of differentiation and the incidence of lymphatic vessel and venous invasion in early Barrett's carcinoma. To this end, a total of 805 endoscopically resected specimens obtained from 472 patients with early Barrett's carcinomas were analysed. The results of this analysis revealed that increasing depth of tumour infiltration is associated with an increase in the incidence of poorly differentiated carcinomas--from 0.8% for lesions limited to the mucosa (m1) to 41.4% when the depth of infiltration extended to the lower third of the submucosa (sm3). A similar correlation was also found for the incidence of lymphatic vessel invasion (m1, 0.6%; sm3, 44.8%) and for venous invasion (m1, 0%; sm3, 13.8%). All of these observations proved to be statistically highly significant (p < 0.001). In conclusion, the results show that the degree of differentiation, as well as the incidence of lymphatic vessel and venous invasion, correlates with the depth of infiltration of the early carcinoma in Barrett's oesophagus.

The pattern of invasion of early carcinomas in Barrett's esophagus is dependent on the depth of infiltration

The differential diagnosis "high-grade intraepithelial neoplasia" or "well-differentiated Barrett's adenocarcinoma limited to the mucosa" is controversial. We investigated 277 endoscopically resected specimens of early Barrett's carcinoma. Depth of infiltration was classified as follows: m 1=carcinoma limited to Barrett's mucosa; m 2=carcinoma infiltrating the neo-muscularis mucosae; m 3=infiltration of the original lamina propria of the esophageal mucosa; m 4=infiltration of the original muscularis mucosae; sm 1, sm 2, and sm 3=infiltration into the upper third, middle third, and lower third of the submucosa. The pattern of invasion was classified and graded as follows: tubular (D 0)=only neoplastic tubuli showing cytologic criteria of malignancy - no tumor cell dissociation; dissociation grade 1 (D 1)=few dissociated tumor cells; D 2=moderate amount of dissociated tumor cells; D 3=pronounced tumor cell dissociation. 74-96% of m 1-m 4 Barrett's carcinomas limited to the mucosa have a D 0-pattern. Tubular invasion decreases only when the submucosa has been infiltrated (sm 1: 70.4%, sm 2: 30.0%, sm 3: 24.0%). Our study shows that the pattern of invasion in early cancer in Barrett's esophagus statistically significantly depends on depth of infiltration.

Misinterpretation of NSAID-induced Colopathy as Crohn's disease

Although NSAID-induced colonopathy characterised by erosions, ulcers, strictures and diaphragms has been known for quite some time, it is not infrequently misinterpreted endoscopically and histologically as Crohn's disease. This is exemplified by the present case history of a 39-year-old man with bloody diarrhoea and a stenosis in the transverse colon that was histologically interpreted as "consistent with Crohn's disease". Treatment with glucocorticoids, however, merely gave rise to adverse reactions. After surgical treatment of the stenosis, the episodes of bloody diarrhoea persisted, and endoscopy continued to reveal erosions and ulcers in the transverse colon. Changing treatment to azathioprine also failed to produce any positive response, merely causing side effects. Subsequent evaluation of the histological specimens by a consultant pathologist turned up the tentative diagnosis of NSAID-induced colonopathy. An analysis of the patient's medical history revealed that he was suffering from Bechterew's disease, for which he had long been taking diclofenac. This case history is a good example of the fact that NSAID-induced enterocolopathy is still too poorly recognised among internists, gastroenterologists and pathologists, and, on the basis of the discontinuous endoscopic and histological findings, is often misinterpreted as Crohn's disease.

Effects of Helicobacter pylori eradication on early stage gastric mucosa-associated lymphoid tissue lymphoma

BACKGROUND & AIMS

Different remission rates of gastric low-grade, B-cell, mucosa-associated lymphoid tissue (MALT) lymphoma have been reported after Helicobacter pylori eradication. We assessed the long-term remission and relapse rates of early stage MALT lymphoma in patients treated only by H pylori eradication and identified factors that might predict outcome.

METHODS

This systematic review analyzed data from 32 studies, including 1408 patients.

RESULTS

The MALT lymphoma remission rate was 77.5% (95% confidence interval, 75.3-79.7), and was significantly higher in patients with stage I than stage II(1) lymphoma (78.4% vs 55.6%; P = .0003) and in Asian than in Western groups (84.1% vs 73.8%; P = .0001). Neoplasia confined to the submucosa regressed more frequently than that with deeper invasion (82.2% vs 54.5%; P = .0001); patients with lymphoma localized to the distal stomach experienced regression more frequently than those with lymphoma of the proximal stomach (91.8% vs 75.7%; P = .0037). The remission rate was higher among patients without the API2-MALT1 translocation than in those with this translocation (78% vs 22.2%; P = .0001). In an analysis of data from 994 patients, 7.2% experienced lymphoma relapse during 3253 patient-years of follow-up evaluation, with a yearly recurrence rate of 2.2%. Infection and lymphoma were cured by additional eradication therapy in all patients with H pylori recurrence (16.7%). Five (0.05%) of the patients initially cured of lymphoma developed high-grade lymphoma within 6 to 25 months of therapy.

CONCLUSIONS

H pylori eradication is effective in treating approximately 75% of patients with early stage gastric lymphoma. Long-term follow-up evaluation of these patients is needed to detect early lymphoma relapse or progression.

No parietal cell hypertrophy of the metaplastic corpus mucosa in the distal esophagus under PPI treatment

When biopsies obtained from short tongues of columnar epithelium in the distal esophagus show only corpus or cardia-corpus transitional mucosa, it remains uncertain whether we are dealing with columnar epithelium metaplasia or a sampling error. In 50 patients with gastro-esophageal reflux disease receiving proton pump inhibitor (PPI) with such tongues of columnar epithelium, we noted that under this treatment, PPI-typical hypertrophy of the parietal cells in the corpus can be found, but not in the corpus or cardia/corpus transitional mucosa in biopsy material obtained from tongues of columnar epithelium in the distal esophagus. These observations may by an indication that in short segments of columnar epithelium corpus, mucosa with no PPI-induced hyperplasia of the parietal cells may be interpreted as metaplastic mucosa.

Follow-up endoscopy in gastroenterology: when is it helpful?

BACKGROUND

The indications for follow-up endoscopy have not been established in all diseases that can be diagnosed by endoscopy.

METHODS

Selective review of the literature and a survey of national guidelines.

RESULTS

In confirmed erosive or non-erosive reflux disease, follow-up endoscopy is indicated only in the presence of complications or Barrett's esophagus. In the case of gastric ulcer or complicated duodenal ulcer, monitoring by endoscopy is mandatory. There is no consensus regarding the indication for follow-up biopsy in confirmed endemic sprue. In an acute episode of confirmed ulcerative colitis, endoscopy is indicated only if the treatment depends on the findings. In confirmed Crohn's disease, this procedure is indicated only in the presence of complications, if the findings are unclear, and before elective intestinal surgery. Those at risk of hereditary colorectal carcinoma without polyposis should undergo colonoscopy annually, starting 5 years before the youngest age of occurrence in their family or at the age of 25 years, whichever comes first.

CONCLUSIONS

With particular reference to further gastrointestinal diseases discussed in the main text, this review unfortunately shows that many of the indications for follow-up endoscopy remain to be ascertained. Controlled studies are needed to establish with sufficient certainty what really helps our patients.

[Neuroendocrine tumor of the esophagus - successful endoscopic treatment of a very rare entity]

HISTORY AND CLINICAL FINDINGS

A 77-year old women presented with dysphagia and loss of weight for two months INVESTIGATIONS, TREATMENT AND DIAGNOSIS: Endoscopy revealed a polypoid tumor was found in the upper third of the esophagus. It was resected endoscopically after a deeper infiltration of the esophageal wall and enlarged lymphadenopathy or distant metastasis had been ruled out. Histology showed a highly differentiated neuroendocrine tumor of the esophagus with beginning infiltration of the submucosa. It was completely resected.

COURSE

The follow-up of 48 months showed no local recurrence or distant metastasis. This case report is the second description of a successful endoscopic treatment of a neuroendocrine tumor of the esophagus.

CONCLUSION

EMR is a diagnostic and therapeutic tool in case of mucosal lesions of the gastrointestinal tract. Highly differentiated localized NET of the esophagus are very rare.

Clinical course of laryngo-respiratory symptoms in gastro-oesophageal reflux disease during routine care--a 5-year follow-up

BACKGROUND

Gastro-oesophageal reflux disease (GERD) can be associated with laryngo-respiratory symptoms (LRS) such as chronic cough, asthma or laryngeal symptoms.

AIM

To analyse the long-term clinical course of LRS in a large population with GERD and LRS.

METHODS

ProGERD is a prospective multicentre cohort study of 6215 adult out-patients with GERD. At baseline, the prevalence of LRS was assessed. Initial standardized treatment was esomeprazole for up to 8 weeks. After 5 years of follow-up, patients were interviewed for LRS and a multivariate analysis was performed with resolved vs. persistent symptoms for chronic cough, asthma and laryngeal symptoms.

RESULTS

In all, 2886 patients (46.4%) were available for analysis at baseline and at 5 years. The prevalence of chronic cough and laryngeal disorders had decreased while the prevalence of asthma had increased. Resolution of LRS was independent of clinical reflux characteristics or PPI medication.

CONCLUSIONS

In a large population with GERD, only few patients reported persistent LRS over 5 years. Resolution of LRS was independent of the stage of GERD and PPI treatment. Accordingly, data on the direction of causality between GERD and LRS are lacking and the strength of the association between the two must remain controversial.

Budesonide is effective in treating lymphocytic colitis: a randomized double-blind placebo-controlled study

BACKGROUND & AIMS

Budesonide is effective in treating collagenous colitis, but no treatment is established for lymphocytic colitis. We performed a randomized, double-blind, placebo-controlled study to evaluate the effects of budesonide in patients with lymphocytic colitis.

METHODS

Forty-two patients (median age, 61 years) with lymphocytic colitis and chronic diarrhea were randomly assigned to groups that were given oral doses of budesonide (9 mg/d) or placebo for 6 weeks. Nonresponders at week 6 were given open-label budesonide (9 mg/d) for 6 additional weeks. A complete colonoscopy and histologic and quality-of-life analyses were performed at baseline and at week 6. The primary end point was clinical remission at 6 weeks, with last observation carried forward (LOCF). All patients who left the study in clinical remission were followed for relapse.

RESULTS

At week 6, 86% of patients given budesonide were in clinical remission (with LOCF) compared with 48% of patients given placebo (P = .010). Furthermore, open-label budesonide therapy induced clinical remission in 7 of 8 patients given placebo. Histologic remission was observed in 73% of patients given budesonide compared with 31% given placebo (P = .030). Only 1 patient discontinued budesonide therapy prematurely. During a mean follow-up period of 14 months, 15 patients (44.1%) experienced a clinical relapse (after a mean of 2 months); 8 of the relapsing patients were retreated with and responded again to budesonide.

CONCLUSIONS

Budesonide effectively induces clinical remission in patients with lymphocytic colitis and significantly improves histology results after 6 weeks. Clinical relapses occur but can be treated again with budesonide.

Serum biomarkers provide an accurate method for diagnosis of atrophic gastritis in a general population: The Kalixanda study

OBJECTIVE

Serological biomarkers can be used for non-invasive diagnosis of gastritis and atrophic gastritis. The aim of this study was to compare the validity of serum levels of pepsinogen I (PGI) and II (PGII), gastrin-17 (G-17) and Helicobacter pylori antibodies (Hpab) with that of the gold standard histology for diagnosis of atrophic gastritis in a population sample from Northern Sweden.

MATERIAL AND METHODS

In all, 1000 subjects underwent endoscopies with biopsies. Serum biomarkers were available in 976 subjects for independent diagnosis of gastric mucosal status using a predetermined diagnostic algorithm.

RESULTS

Overall agreement between histology and serological biomarkers in diagnosing corpus atrophy was 96% (CI 95%: 95-97%). Sensitivity and specificity of markers for atrophic gastritis were 71% (CI 68-74%) and 98% (CI 97-99%) respectively, corresponding to 69% (CI 95%: 66-72%) and 98% (95% CI 97-99%) positive and negative predictive values. The positive likelihood ratio was 35.5 (95% CI: 35.0-36.0%). In subgroups with normal stomachs, H. pylori non-atrophic gastritis and H. pylori-negative gastritis by histology, the prevalence of corpus atrophy diagnosed with the biomarkers was 0.8% and 4.9%, respectively. In total, 6.6% of subjects in the study population had corpus atrophy according to the serological biomarkers. CONCLUSIONS. Serological biomarkers show a high degree of accuracy as a non-invasive method to diagnose corpus atrophy, which is common in the general population.

Identification of novel cyclooxygenase-2-dependent genes in Helicobacter pylori infection in vivo

BACKGROUND

Helicobacter pylori is a crucial determining factor in the pathogenesis of benign and neoplastic gastric diseases. Cyclooxygenase-2 (Cox-2) is the inducible key enzyme of arachidonic acid metabolism and is a central mediator in inflammation and cancer. Expression of the Cox-2 gene is up-regulated in the gastric mucosa during H. pylori infection but the pathobiological consequences of this enhanced Cox-2 expression are not yet characterized. The aim of this study was to identify novel genes down-stream of Cox-2 in an in vivo model, thereby identifying potential targets for the study of the role of Cox- 2 in H. pylori pathogenesis and the initiation of pre- cancerous changes.

RESULTS

Gene expression profiles in the gastric mucosa of mice treated with a specific Cox-2 inhibitor (NS398) or vehicle were analysed at different time points (6, 13 and 19 wk) after H. pylori infection. H. pylori infection affected the expression of 385 genes over the experimental period, including regulators of gastric physiology, proliferation, apoptosis and mucosal defence. Under conditions of Cox-2 inhibition, 160 target genes were regulated as a result of H. pylori infection. The Cox-2 dependent subset included those influencing gastric physiology (Gastrin, Galr1), epithelial barrier function (Tjp1, connexin45, Aqp5), inflammation (Icam1), apoptosis (Clu) and proliferation (Gdf3, Igf2). Treatment with NS398 alone caused differential expression of 140 genes, 97 of which were unique, indicating that these genes are regulated under conditions of basal Cox-2 expression.

CONCLUSION

This study has identified a panel of novel Cox-2 dependent genes influenced under both normal and the inflammatory conditions induced by H. pylori infection. These data provide important new links between Cox-2 and inflammatory processes, epithelial repair and integrity.

Helicobacter pylori cag-Pathogenicity island-dependent early immunological response triggers later precancerous gastric changes in Mongolian gerbils

Infection with Helicobacter pylori, carrying a functional cag type IV secretion system (cag-T4SS) to inject the Cytotoxin associated antigen (CagA) into gastric cells, is associated with an increased risk for severe gastric diseases in humans. Here we studied the pathomechanism of H. pylori and the role of the cag-pathogenicity island (cag-PAI) for the induction of gastric ulcer and precancerous conditions over time (2-64 weeks) using the Mongolian gerbil model. Animals were challenged with H. pylori B128 (WT), or an isogenic B128DeltacagY mutant-strain that produces CagA, but is unable to translocate it into gastric cells. H. pylori colonization density was quantified in antrum and corpus mucosa separately. Paraffin sections were graded for inflammation and histological changes verified by immunohistochemistry. Physiological and inflammatory markers were quantitated by RIA and RT-PCR, respectively. An early cag-T4SS-dependent inflammation of the corpus mucosa (4-8 weeks) occurred only in WT-infected animals, resulting in a severe active and chronic gastritis with a significant increase of proinflammatory cytokines, mucous gland metaplasia, and atrophy of the parietal cells. At late time points only WT-infected animals developed hypochlorhydria and hypergastrinemia in parallel to gastric ulcers, gastritis cystica profunda, and focal dysplasia. The early cag-PAI-dependent immunological response triggers later physiological and histopathological alterations towards gastric malignancies.

Comparison of histological parameters for the diagnosis of eosinophilic oesophagitis versus gastro-oesophageal reflux disease on oesophageal biopsy material

AIMS

Eosinophil infiltration of the oesophageal epithelium is the cardinal pathomorphological finding in eosinophilic oesophagitis (EO), but gastro-oesophageal reflux disease (GORD) is also associated with increased eosinophils. The aim was to compare histological parameters for the diagnosis of EO versus GORD on routinely taken biopsy specimens.

METHODS AND RESULTS

One hundred and five routine biopsy specimens with EO (n = 62), GORD (n = 24) and probable EO (n = 19) from 74 patients (52 men, 22 women; mean age 43.7 years) were analysed for numbers of eosinophils, mast cells, degranulation and qualitative changes of oesophageal epithelium using immunohistochemistry with monoclonal antibodies against eosinophil peroxidase and eosinophil major basic protein and mast cell tryptase. Eosinophil infiltration was significantly higher in EO than in GORD both on haematoxylin and eosin staining (54.8 versus 9.1; P < 0.05) and immunohistochemistry (77.5 versus 24.7; P < 0.05). Eosinophil degranulation was significantly more intense in EO than in GORD (1.16 versus 0.41; P < 0.05). Furthermore, eosinophilia-codependent secondary qualitative changes of squamous epithelium in EO were generally more extensive than those in GORD.

CONCLUSIONS

Histological differential diagnosis of EO and GORD should be based on eosinophil counts, secondary morphological changes of eosinophils and oesophageal squamous epithelium, especially in cases suspicious of EO.

Investigational treatment options in microscopic colitis

Collagenous and lymphocytic colitis are the two recognized major presentations of microscopic colitis. Both diseases present with chronic watery diarrhea and a chronic inflammatory infiltrate in the colonic mucosa without specific endoscopic abnormalities, and hence diagnosis is established by histology. Recent epidemiological studies suggest that microscopic colitis may affect as many patients as Crohn's disease or ulcerative colitis. The cause of these diseases is unknown; however, several lines of evidence support the hypothesis of mucosal injury from an unknown agent in the fecal stream. Due to the lack of disease causality, therapeutic management of microscopic colitis is now directed primarily at symptoms' resolution or improvement. Based on current evidence, oral budesonide represents an effective treatment option for patients with microscopic colitis to achieve and maintain remission. Other anti-inflammatory drugs such as mesalazine or bismuth subsalicylate are now under evaluation. The optimal long-term management strategy of microscopic colitis, however, remains an unsolved issue.

Silencing of MGMT expression by promoter hypermethylation in the metaplasia-dysplasia-carcinoma sequence of Barrett's esophagus

To determine the relevance of MGMT in Barrett's carcinogenesis, we analyzed promotor hypermethylation and expression of MGMT in Barrett's adenocarcinomas and its paired precursor lesions from 133 patients using a methylation-specific PCR, real-time RT-PCR and immunohistochemistry. Hypermethylation was detected in 78.9% of esophageal adenocarcinomas, in 100% of Barrett's intraepithelial neoplasia, in 88.9% of Barrett's metaplasia, but only in 21.4% of normal esophageal mucosa samples (P<0.001) and correlated significantly with downregulation of MGMT transcripts (P=0.048) and protein expression (P=0.02). Decrease of protein expression was significantly correlated with progressed stage of disease, lymph node invasion and tumor size. We conclude, that aberrant promoter methylation of MGMT is a frequent and early event during tumorigenesis of Barrett's esophagus. High prevalence of MGMT hypermethylation may represent a candidate marker for improved diagnosis and targeted therapy in Barrett's adenocarcinoma.

Critical reappraisal of current surveillance strategies for Barrett's esophagus: analysis of a large German Barrett's database

Endoscopic surveillance is recommended for patients with Barrett's esophagus (BE). Based on a large database, gathered from predominantly community-based practices in Germany, we aimed to investigate the time-course of malignant progression and apply these findings to current clinical practice. Data of 1438 patients with BE from a large German BE database were analyzed. Patients with at least one follow-up endoscopy/biopsy were included. Detection of 'malignant Barrett' (either high-grade intra-epithelial neoplasia or invasive adenocarcinoma) was considered as study end-point. Of 1438 patients with BE, 57 patients had low-grade intra-epithelial neoplasia (LG-IN) on initial biopsy and 1381 exhibited non-neoplastic BE. 'Malignant Barrett' was detected in 28 cases (1.9%) during a median follow-up period of 24 months (1-255), accounting for an incidence of 0.95% per patient year of follow-up. The frequency of 'malignant Barrett' was significantly higher (P < 0.001, chi(2)-test) in the LG-IN group (n = 11, 19.3%) compared with the non-neoplastic BE group (n = 17, 1.2%). In the non-neoplastic BE group, 'malignant Barrett' was predominantly found during re-endoscopy within the first year of follow-up (12 of 17; 70.6%), in contrast to the LG-IN group, in which 'malignant Barrett' was observed predominantly after a time exceeding 12 months (8 of 11, 72.7%; P = 0.05, Fisher's exact test). Initial endoscopic evaluations seem to play the most crucial role in managing BE. After 1 year of follow-up, endoscopic surveillance should be focused on patients with LG-IN. In patients with repeatedly proven non-neoplastic BE, elongation of the follow-up intervals to the upper limit of current guidelines, that is, 5 years, might be justified.